Transformational change in health and care: reports from the field

The King’s Fund has been calling for transformational change to respond to the growing pressures and demands in the health and care system. We have argued that transformation is best brought about ‘from within’, led by frontline staff and service users, and that it needs collaborative and distributed leadership styles.

To offer insights to help strengthen transformation efforts, we selected four sites that have been recognised as successful transformation initiatives.

• The Bromley by Bow Centre: an innovative community organisation in East London that works with its Health Partnership to transform the lives of people in one of the UK’s most deprived boroughs.

• Birmingham and Solihull NHS Mental Health Trust: Rapid Assessment, Interface and Discharge (RAID) is a multidisciplinary mental health service that has been transforming liaison psychiatry across the acute hospitals in Birmingham.

• Northumbria Healthcare NHS Foundation Trust: Northumbria Specialist Emergency Care Hospital is a purpose-built facility that opened in 2015 to transform emergency care across a large geographical area.

• Buurtzorg Nederland: a novel care model that has received international acclaim for transforming community care through its nurse-led, cost-effective approach.

We interviewed 42 people who were involved in leading, supporting, delivering, receiving or witnessing the changes. Our report presents stories of transformational change drawing on their collective experiences and reflections.

Two key messages emerged. First, there are groups who work tirelessly to achieve great things – the stories are a tribute to their determination, bravery and resilience. Second, there are key considerations for health and care leaders working to achieve transformational change.

Making transformational change work

We hear from the leaders from our four case study sites – in Birmingham, Bromley by Bow, Northumbria and Buurtzorg –about their transformational change projects, what made them a success, what impact they had on patients and staff, and their advice for implementing transformational change in health and social care settings.

A new approach to transformational change

The definition of transformational change is the emergence of an entirely new state prompted by a shift in what is considered possible or necessary which results in a profoundly different structure, culture or level of performance. In health and care, the concept of transformational change is complicated by the context. It calls into question what is meant by the term ‘transformational change’ in health and care.

The stories of Bromley by Bow, Birmingham, Northumbria and Buurtzorg illustrate that transformation is multi-layered, messy, fluid and emergent. It is not merely about changing how a service operates, but also about shifting mindsets, changing relationships and re-distributing power. Our stories suggest that transformational change requires the use of organic methods that centre around a core purpose of improving people’s lives, allowing models and plans to develop around this. This resonates with Don Berwick’s advice to favour ‘curiosity and invitation’ rather than ‘command and control’.

There is a tension in the current system between the time needed for transformation and the sense of urgency for it to happen. Therefore, two things are key:

• a strengthened focus on how we learn together as a health and care system, understanding and connecting efforts, and building from this rather than starting afresh. This requires time and support to build skills, relationships and confidence

• a form of leadership that is collaborative and distributed, bringing together people from disparate groups to harness their collective potential.

Challenges to face

Our stories show that staff working in health and care are motivated by a vision of safe care and better ways to deliver quality. But in the face of a need to transform, there can also be a sense of inertia and preservation of the status quo. This needs further study to understand and address the underlying causes.

The nature and uses of power to ensure positive impact is important. Our stories show examples of old power (held by a few, closely guarded and inaccessible) colliding with new power (enabled by people at a grassroots level who have agency). However, they also demonstrate how old power can enable new power. There is a need to develop skilful leadership practices that can work across both domains.

A pressing dilemma for those we interviewed was how to work effectively within current system constraints while also championing fundamentally different structures to support transformation. It is likely, in the short term, that a dual focus is needed by working within existing limitations while also nurturing new ways. In the longer term, wider debate is needed about how best to propagate these efforts through the presence of a learning and supportive system that can enable and sustain great change.

When organisations or services embark on transformational change there are often tensions between radical innovation and protecting people from harm; between pace of change and taking time to engage people fully; between focusing on frontline care now or the less ‘visible’ opportunity to prevent ill health in the future. Hence, there are questions about the scale of transformation and what ‘success’ looks like. Our stories imply that the answers lie with communities and frontline staff. If that is the case, there is a need to reconsider who is leading and driving current transformational change.

Opportunities and untapped potential

Across our examples, transformations were sparked by people seeing and acting on local needs. The human motivation to make a difference was very powerful. Previous experiences of leaders, their access to broad networks of experts, and the skills to understand academic resources helped the ‘sparks’ to become ‘flames’. More needs to be done to help people to nurture change sparks and bring about change.

Communities also displayed the power to make change: driving health and care innovations, providing ideas that shaped new primary care models, reshaping plans for hospital provision, sparking career choices that transformed care across cities, regions and countries. There is a need to reconsider the relationship between health and care organisations and communities and service users.

Our stories suggest that technology that makes it easier and simpler for staff to do their work to provide quality support for the people who need it is critical. Data can be a powerful tool in transformation, as can stories, experiences and relationships. Transformational efforts can be strengthened by building on this.

The need for transformational leadership

Our stories show the need for individuals with skills to kick-start and drive through transformation in a way that is inspiring, approachable and supportive. They also show the importance of ‘sponsorship’ by forward-thinking commissioners, politicians, managers and those willing to work around system constraints to enable testing of these new ways.

The stories show the need to understand staff and create positive cultures that enable transformational change. Maintaining a focus on team members’ motivation, which often draws on a desire to make meaningful improvements for patients, can be a source of personal joy. Our work on collective leadership shows the importance of developing cultures to support effective teamworking.

Our stories show the importance of proactively identifying invisible forces with an open and enquiring mind. For example, recognising the value of physical spaces and personal contact, the impact of job titles, the diversity of attitudes and preferences, or the presence of less visible needs in the community. These forces can be both invisible and impassable, terminating transformational change efforts or steering them towards difficulty unless surfaced early and dealt with skilfully.

We also heard about the power of staff and communities to drive transformation: the importance of giving people time and space to think through the purpose of transformation; to understand the struggles and worries they face; to offer support instead of demanding change with no time to prepare or engage. More fundamentally, our stories show the need to reconsider the structures that impact on their ability to do this – regulation, funding, training, organisational cultures – and to create ways to make it easier for staff to lead transformational change efforts.

A collective focus

Transformational change in health and care requires our collective focus to address the areas highlighted in this report: to strengthen understanding and approaches, to create effective ways of dealing with the barriers, to unlock the tremendous human potential of staff and communities, to optimise the environment to ensure it supports them, and to foster the collaborative leadership that can bring about transformation.